A newspaper on my neighbour’s stoop declares a Historic Drought in New England, but in my hospital’s basement, water leaks from the ceiling. A yellow sign warns of the “Wet Floor” with a cartoon man in free fall, seconds away from his own trip to the emergency department. In our triage area, a pool of patients stretches out on beds that extend down the hallway. Beyond them, in the collective treatment area, is a flood.
My attending likes to start shifts by asking about our daily goals. An intern says he wants to complete sepsis bundles; a second-year is shooting for more bedside ultrasounds. As the senior resident, I say I’m working on “volume,” but what I really mean is flow. I don’t admit it out loud, but I’m wondering if it’s possible to have a perfect shift, to glide smoothly from one patient to the next just once before I graduate. It would be beautiful, like a high dive without splash.
As our huddle ends, I assign myself to three patients. On my way to the first, a man intercepts me and asks how much longer he will wait to be seen.
“I ask because, you know, the squeaky wheel gets the grease,” he winks.
To see him now would delay me from the patients I have already claimed. A good answer to his question will also take time. He has already been triaged, so I tell him that someone will see him soon. As I leave, I pass a man handcuffed to his stretcher and another man with gauze around his head. A circle of blood is spreading on his forehead like a bandanna of the flag of Japan. I want to help them all, but those two also have to wait.
In his mid-twenties, my first patient overdosed on a cocktail of illegal pills a few hours ago. He is not suicidal and does not want drug rehab. He wants to talk, mostly to apologize. I think there might be hope for him, until he tries to convince me that he can leave, despite being too high to walk. This man needs more than me, more than an emergency department, and until he gets the help he needs, I know he’ll come back to me, back to this emergency department. We focus on how I can help him, how he can help himself, but we cannot talk as long as I’d like. In my head, a tide is coming in, and I am running out of time – as long as my name is assigned to my other two patients, no other doctor will see them.
I try to move on, but he asks me, “Can I get a cup of water?”
I want to do this for him as a courtesy, to convince him that we’re on the same team, but I explain that he had just vomited, that unfortunately the closest water dispenser happens to be broken today but that I can order fluid to flow directly into his veins.
“That is so much better,” he nods, then closes his eyes.
A moment later, a woman points over my shoulder, and I swing around to see the patient who overdosed waving at me.
“Can I get a cup of water?” he pleads, having changed his mind.
I fetch him some water, and the tide rises higher.
I find my next patient sitting upright in her stretcher. She’s been short of breath for days. Her heartbeat is pulsing in her neck, and her legs are swollen. They dimple like memory foam when I touch them.
“My doctor decreased the dose of my water pill,” she explains. “Now look, I blew up like a balloon.”
She is drowning in her own circulation. The plan, though, is easy: double the dose of her diuretic, call her doctor, monitor urine output, see the next patient. As the tide comes in, I’ve recouped some time. Though every patient I evaluate is another patient seen, it is also a patient not seen – someone else is always waiting and will have to wait longer. Flow, I’m beginning to realize, is not a synonym for ease or productivity. It is a form of redistribution. Of help I could give to one patient by withholding it from another, of patients back and forth into the streets, from our department into another.
The 62-year-old man I am looking for next is nowhere to be found – not in his stretcher and not in the corridors. Hoping that he’ll turn up in the next three minutes, I steal time to use the bathroom on the way back to my computer. When I take a precious minute to log in and enter orders on my first two patients, I see that six new patients have arrived in the time it took me to speak with two. An ocean’s rim of patients. How nice a drought would feel.
“Do you want a catheter in that guy?” a nurse appears and asks.
“What guy?”
“The urinary retention guy,” she says.
“Where is he?”
“He’s been back and forth to the bathroom,” she explains. “Says he can’t pee for two days.”
Hours later, after the catheter for my third patient drains a liter of fluid, after the intoxicated patient goes home and the woman with heart failure is admitted, I return to the staff room, and the intern asks me about flow. How to improve it. What I do. I realize that he is sitting in the same chair in which I sat as an intern and asked a senior the exact same question. At the time, I had rushed to see so many patients that each person I saw felt like an obstacle to the next, until I saw, really saw, no people at all.
“How many patients should I pick up at once?” he asks.
I remember all the conflicting advice I received, and how I never learned the answer. I just stopped asking others.
“Try two at a time,” I say. “See how it goes.”